Open lung biopsy in the immunosuppressed patient

Abstract

Considerable disparity of opinion exists concerning the risk: benefit ratio of open lung biopsy in immunosuppressed patients. Eighty-three consecutive patients who underwent open lung biopsy were analyzed, and 70 of the 83 (84 percent) patients were immunosuppressed. A specific etiologic diagnosis was obtained by open lung biopsy in 46 of 83 (55 percent) patients, and a nonspecific diagnosis in 37 of 83 (45 percent). Of 53 specific diagnoses in the 46 patients, 15 (28 percent) were infection and 35 (61 percent) were neoplasm. Diagnostic errors occurred twice, for a diagnostic accuracy of 97.5 percent (81 of 83). A change in treatment was dictated by biopsy results in 37 of 83 (45 percent) patients. No deaths were directly attributable to the operative procedure, but surgical complications occurred in eight of 83 (9.6 percent) cases. Hospital mortality rate was 25 percent (21 of 83); late mortality rate was an additional 40 percent (25 of 62) with an average follow-up of 9.7 months. Of those patients whose lung biopsies dictated a change in treatment, eight of 37 (22 percent) died in the hospital; of those with no treatment change indicated, 13 of 46 (28 percent) died (p = N.S.). Patients whose biopsies yielded a specific diagnosis fared no better than those without diagnosis (hospital mortality 26 percent [12 of 46] versus 24 percent [nine of 37], p = N.S.), a finding at variance with previously published series. Total cumulative mortality rate for immunosuppressed patients was 63 percent (44 of 70). Only two of 13 nonimmunosuppressed patients died (cumulative mortality rate 15 percent). Financial analysis revealed that the cost of caring for these desperately ill patients is exceedingly high. Open lung biopsy is an accurate diagnostic tool with low surgical mortality and acceptable morbidity. Thoughtful individual consideration must be given to each case, with realistic assessment made of the benefits likely to result from a definitive diagnosis, given the patient's underlying disease and current state of health. Appropriate selection of patients for open lung biopsy is recommended, with aggressive early diagnosis and management of pulmonary infiltrates before multisystem failure has occurred.